NU373 Week 5 EAQ Evolve Elsevier: Stress & Coping
Which medications are used as the first-line treatment for post-traumatic stress disorder (PTSD)? Select all that apply. o Sertraline o Paroxetine o Phenelzine o Venlafaxine o Amitriptyline
o Sertraline o Paroxetine · Sertraline and paroxetine are selective serotonin reuptake inhibitors that are approved by the US Food and Drug Administration as a first-line treatment for PTSD. If these medications are ineffective, the use of phenelzine, venlafaxine, or amitriptyline is indicated.
The nurse provides care for a client with a long history of alcohol abuse. Which medication would the nurse anticipate will be prescribed for the client to prevent symptoms of withdrawal? o Lorazepam o Phenobarbital o Chlorpromazine o Disulfiram
o Lorazepam · Lorazepam is most effective in preventing the signs and symptoms associated with withdrawal from alcohol. It depresses the central nervous system by potentiating gamma-aminobutyric acid, an inhibitory neurotransmitter. Phenobarbital is used to prevent withdrawal symptoms associated with barbiturate use. Chlorpromazine, an antipsychotic medication, is not used for alcohol withdrawal. Disulfiram does not prevent symptoms; it is aversion therapy that causes symptoms when alcohol is ingested.
Which medication is indicated for management of clinical manifestations associated with an opioid overdose? o Naloxone o Methadone o Epinephrine o Amphetamine
o Naloxone · Naloxone is a narcotic antagonist that displaces opioids from receptors in the brain, thereby reversing respiratory depression. Methadone is a synthetic opioid that causes central nervous system depression; it will add to the problem of overdose. Epinephrine and amphetamine will have no effect on respiratory depression related to opioid overdose.
Which parameter would be assessed to determine the degree of anxiety being experienced by the client? o Memory state o Creativity level o Perceptual field o Delusional system
o Perceptual field · Perceptual fields would be assessed to determine the degree of anxiety because the perceptual fields narrow as anxiety increases. Memory state, creativity level, and delusional system are not related directly to anxiety level and are not parameters to determine degree of anxiety.
Which response would the nurse make to a client who is experiencing alcohol withdrawal syndrome and says, "Bugs are crawling all over me and my bed"? o "Just try to brush them off." o "I don't see any bugs on you or your bed." o "They'll go away when you start feeling better." o "The bugs that you see are just the design on the bedspread."
o "I don't see any bugs on you or your bed." · The nurse would use the response, "I don't see any bugs on you or your bed." This statement points out reality and does not support the client's hallucinations. The response, "Just try to brush them off," supports the client's hallucination and provides false reassurance. The response, "They'll go away when you start feeling better," supports the client's hallucination and provides false reassurance. The response, "The bugs that you see are just the design on the bedspread," constitutes false information. If the client said that the bugs were only on the bed and the bedspread had a design, then the client might have been experiencing an illusion.
Which nursing action would be appropriate when the client with alcohol withdrawal delirium begins experiencing hallucinations? o Withholding intervention, because the client may be having vivid dreams o Asking the client to describe the hallucinations and explaining that they are not real o Administering the prescribed medication to the client to subdue the agitated behavior o Pretending to visualize the imaginary things the client is describing to foster acceptance
o Administering the prescribed medication to the client to subdue the agitated behavior · The nurse would administer the prescribed medication to the client to subdue the agitated behavior. Alcohol withdrawal delirium is a life-threatening situation. The client's central nervous system (CNS) is overstimulated, and seizures and death can occur. CNS-depressant medications, usually benzodiazepines, are needed to blunt the withdrawal effects. The client needs intervention because the hallucinations are not dreams. Focusing on the hallucinations associated with the withdrawal syndrome is not therapeutic; it is not helpful to tell the client that the hallucinations are not real, because they are real to the client. Pretending to visualize the imaginary things is not helpful and may be unsafe. The nurse must present reality.
Place these crisis interventions in the order the nurse would implement them for a client experiencing escalating levels of anxiety. o Provide firm but kind directions. o Attempt to identify the source of the anxiety. o Place the client in restraints if deemed dangerous. o Encourage deep breathing and relaxation techniques.
o Attempt to identify the source of the anxiety. o Encourage deep breathing and relaxation techniques. o Provide firm but kind directions. o Place the client in restraints if deemed dangerous. · The sequence the nurse would follow is: (1) attempt to identify the source of the anxiety, (2) encourage deep breathing and relaxation techniques, (3) provide firm but kind directions, and (4) place the client in restraints if deemed dangerous. Mild anxiety is addressed best with attempts to identify the source so that it can be eliminated or coping mechanisms can be initiated. Moderate anxiety requires refocusing, which can include deep breathing and relaxation techniques. In severe anxiety the client begins to lose control and benefits from firm but kind direction. Panic-level anxiety results in the client having a strong need to escape the discomfort, so the client can become a danger to self or to others. Restraints would be considered and implemented only as a last option to ensure the client's safety and that of the milieu.
Which action would the nurse anticipate taking when a client with anxiety begins hyperventilating and reports feeling dizzy? o Administering oxygen o Offering an incentive spirometer o Having the client breathe in and out of a paper bag o Administering intravenous sodium bicarbonate
o Having the client breathe in and out of a paper bag · The client's dizziness is likely caused by respiratory alkalosis secondary to hyperventilation. Breathing in and out of a paper bag leads to rebreathing exhaled carbon dioxide and resolves the respiratory alkalosis. Administering oxygen is not necessary because there is no evidence of hypoxia. There is no evidence that the client needs an incentive spirometer to prevent atelectasis. The client is already alkalotic; bicarbonate ions will increase the problem.
Which method would the nurse use to help a client ease anxiety? o Avoiding unpleasant events o Prolonging exposure to fearful situations o Introducing an element of pleasure into fearful situations o Helping the client acquire skills with which to face stressful events
o Helping the client acquire skills with which to face stressful events · The nurse would help the client acquire skills with which to face stressful events. Learning a variety of coping mechanisms helps reduce anxiety in stressful situations. A person must learn to cope with unpleasant events; they cannot be avoided. Prolonged exposure may increase anxiety to possibly uncontrollable levels. Fearful situations can never be viewed as pleasurable.
Which action would the nurse take first for a client with a generalized anxiety disorder? o Encourage the client to exercise on a daily basis. o Have the client list the behaviors used to reduce anxiety. o Remove as many stimuli from the client's environment as possible. o Administer as-needed medications prescribed by the primary health care provider.
o Remove as many stimuli from the client's environment as possible. · The first action the nurse would take is to remove as many stimuli from the client's environment as possible. Removing as many stimuli from the client's environment helps reduce the client's anxiety by limiting the factors that must be confronted; decreasing stimuli usually decreases anxiety. Although exercising can help decrease anxiety, it is not the first action the nurse would take; this would follow later in the treatment. The anxiety level must be decreased before the client is asked to discuss coping strategies. Administering as-needed medications prescribed by the primary health care provider may or may not be necessary; it is not the first intervention.
A client has been diagnosed with generalized anxiety disorder (GAD). Which behavior would the nurse expect to observe? o Making huge efforts to avoid "any kind of bug or spider" o Experiencing flashbacks to an event that involved a sexual attack o Spending hours each day worrying about something "bad happening" o Becoming suddenly tachycardic and diaphoretic for no apparent reason
o Spending hours each day worrying about something "bad happening" · Using worrying as a coping mechanism is a behavior characteristic of GAD. Avoiding bugs and spiders would indicate a phobia. Flashbacks to traumatic events are characteristic of post-traumatic stress disorder (PTSD). Experiencing an accelerated heart rate and perfuse sweating for no apparent reason is consistent with a panic attack.
Which action would the nurse take when caring for a client having an acute episode of anxiety? Select all that apply. o Staying with the client o Giving brief directions o Using short, simple sentences o Linking the client's behavior to feelings o Teaching a cognitive therapy principle o Having the client write an assessment of strengths
o Staying with the client o Giving brief directions o Using short, simple sentences o Linking the client's behavior to feelings o Teaching a cognitive therapy principle o Having the client write an assessment of strengths · Staying with the client conveys acceptance and the ability to give help. Giving brief directions reduces indecision. Using short, simple sentences promotes comprehension. Linking the client's behavior to feelings promotes self-awareness. Cognitive therapy principles provide a basis for behavioral change. Writing an assessment of strengths increases self-acceptance.
For a client who is increasingly agitated, which immediate nursing intervention is most likely to increase anxiety? o Being assertive o Responding early o Providing choices o Teaching relaxation
o Teaching relaxation · Once the client is agitated, teaching will not be effective. Learning requires attention and participation; failure to learn will increase the client's anxiety. Teaching relaxation techniques can be done once the client calms down. Being assertive (not aggressive) shows the client that the nurse is confident in handling the situation. This may help reduce the client's anxiety. Responding before agitation escalates makes interventions more likely to be successful. Providing choices may help the client feel less threatened and avoids a power struggle.
Which substance is considered addictive in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)? Select all that apply. o Alcohol o Caffeine o Cannabis o Gambling o Hallucinogens o Antianxiety medications
o Alcohol o Caffeine o Cannabis o Gambling o Hallucinogens o Antianxiety medications · Alcohol, caffeine, cannabis, hallucinogens, and antianxiety medications are all considered substances of abuse in the DSM-5. Tobacco, opioids, inhalants, sedatives, hypnotics, and stimulants are also listed. Behaviors are gradually being recognized as addictive. For example, gambling was officially declared a disorder in 2013.
Which statement by the nurse indicates understanding of DSM-5 criteria for post-traumatic stress disorder (PTSD)? Select all that apply. o "Feelings of self-worth remain high." o "PTSD does not occur in children younger than 6 years of age." o "Clients will remember all details of the event." o "A person directly witnessed a traumatic event." o "Flashbacks must last for longer than 1 month." o "Derealization means feeling detached from your body."
o "Flashbacks must last for longer than 1 month." · To meet the DSM-5 criteria for PTSD, the duration of intrusive symptoms (disturbing dreams, flashbacks, negative mood, and alterations in reactivity) must occur for more than 1 month. Clients with PTSD frequently demonstrate persistent negative beliefs about themselves. PTSD can occur in clients of any age, though the DSM-5 criteria are modified for children younger than 6 years of age. Clients frequently cannot remember important aspects of the traumatic event. Exposure to an actual or threatened event can cause PTSD. Derealization is a persistent experience of unreality; depersonalization means feeling detached from your body.
Which response would the nurse make to a client with a history of obsessive-compulsive behaviors who on the day of the part-time job interview arrives at the mental health center with signs of anxiety? o "I know you're anxious, but by forcing yourself to go to the interview you may conquer your fear." o "If going to an interview makes you this anxious, you're probably not ready to go back to work." o "It must be that you really don't want that job after all. I think you should reconsider going to the interview." o "Going for your interview triggered some feelings in you. Perhaps you could call a friend to drive you there."
o "Going for your interview triggered some feelings in you. Perhaps you could call a friend to drive you there." · The nurse would say, "Going for your interview triggered some feelings in you. Perhaps you could call a friend to drive you there." The symptoms are a defense against anxiety resulting from decision-making, which triggers old fears; the client needs support. Forcing the client to go to the interview ultimately denies the client's overwhelming anxiety and lacks realistic support. Stating that the client is not ready to go back to work is judgmental; the client should be encouraged to work through symptoms, not avoid risk. Stating that the client doesn't really want the job is judgmental; an increase in anxiety does not necessarily mean the client does not want to attain the goal.
Which initial response would the nurse make to a client undergoing alcohol detoxification who asks about attending Alcoholics Anonymous (AA) meetings after discharge? o "You'll find that you'll need their support." o "How do you feel about going to those meetings?" o "They'll help you learn how to cope with your problem." o "Don't you think it's better to wait until you're sure that you're ready?"
o "How do you feel about going to those meetings?" · "How do you feel about going to those meetings?" focuses on the client's feelings rather than on the organization itself. The organization is effective when the client is able to discuss feelings openly without fear of ridicule or judgment. "You'll find that you'll need their support" may or may not be true, and it is too early in treatment for this response. "They'll help you learn how to cope with your problem" is false reassurance and it is premature; AA may help clients develop insight, but the initial focus would be on the client's feelings. "Don't you think it's better to wait until you're sure that you're ready?" does not focus on the client's feelings and may be discouraging; this sounds like the nurse is expressing doubt.
The nurse teaches a client about ways to manage stress and anxiety. Which statement by the client indicates the need for further instruction? o "I should avoid exercise to prevent physical stress on the body." o "Journaling can help identify stressors and other things that are causing anxiety." o "Trying to find humor in a stressful situation can help make it easier to deal with." o "Reframing a negative situation in a positive light can help me change my perception about the situation."
o "I should avoid exercise to prevent physical stress on the body." · Exercise is especially helpful in reducing symptoms of anxiety and depression. It does not cause physical stress, worsening mental stress, or anxiety. Journaling, humor, and cognitive reframing (examining a negative situation in a positive light) are all effective strategies for reducing stress and anxiety.
An antianxiety medication is prescribed for an extremely anxious client. The client states, "I'm afraid to take this medication because I heard it's addictive." Which response by the nurse is most appropriate? o "This medication rarely causes dependence when the dosage is controlled." o "You may require increases in your dosage; however, it rarely causes dependence." o "It usually results in psychological but not physiological dependence." o "The medication has the potential for physiological and psychological dependence."
o "The medication has the potential for physiological and psychological dependence." · Antianxiety medications have the potential for physiological and psychological dependence; the nurse would teach the client about both the advantages and disadvantages of taking this medication. Physiological or psychological dependence may develop even when the dosage is controlled. Tolerance does develop and can lead to dependence.
Which initial question by the nurse would be most therapeutic to alleviate the anxiety of the client who is pacing the floor and appears extremely anxious? o "What's made you so upset?" o "Where would you like to walk with me?" o "Shall we sit down to talk about your feelings?" o "How would you like to go to the gym to work out?"
o "Where would you like to walk with me?" · The nurse would ask, "Where would you like to walk with me?" The nurse's presence may provide the client with support and a feeling of control. Asking what has upset the client may lead to more anxiety. The client is too distraught to sit; to be therapeutic the nurse would walk with the client, thereby demonstrating concern. The client is in a panic; anger is not the primary emotion and there is no need to work off aggression.
Which statement would the nurse make to a client with generalized anxiety disorder who asks, "What can I do to keep myself from overreacting to stress?" o "Try to recognize the problem." o "Improve your time-management skills." o "Ignore situations that affect you deeply." o "Work on identifying and developing coping strategies."
o "Work on identifying and developing coping strategies." · Developing a wide variety of coping strategies increases the individual's ability to cope with stress; different defenses can be used in various anxiety-producing situations. The client has already identified the problem and does not need help recognizing the problem. Improved time-management skills do not pertain to overreacting to stress, and time management may or may not be helpful. People should not ignore situations that affect them deeply; this does not help the client learn to cope.
Which vital sign findings would alert the nurse to a client's opioid overdose? o 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths per minute o 180/100 mm Hg, tachycardia, and respiratory rate of 18 breaths per minute o 120/80 mm Hg, regular pulse, and respiratory rate of 20 breaths per minute o 140/90 mm Hg, irregular pulse, and respiratory rate of 28 breaths per minute
o 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths per minute · A blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths per minute would alert the nurse to an opioid overdose. Opioids cause central nervous system depression, resulting in severe respiratory depression, hypotension, tachycardia, and unconsciousness. The other findings, particularly the respirations, are not indicative of an overdose of an opioid.
Which signs and symptoms would the nurse observe in a client experiencing alcohol withdrawal? Select all that apply. o Fatigue o Anxiety o Runny nose o Diaphoresis o Psychomotor agitation
o Anxiety o Diaphoresis o Psychomotor agitation · Anxiety, diaphoresis, and psychomotor agitation all occur with alcohol withdrawal. Anxiety is commonly associated with withdrawal from alcohol. When a person is withdrawing from alcohol, associated autonomic hyperactivity causes an increased heart rate and diaphoresis. The withdrawal of alcohol affects the central nervous system, resulting in excited motor activity (psychomotor agitation). Fatigue is associated with withdrawal from caffeine or stimulants. A runny nose and tearing of the eyes are associated with withdrawal from opioids.
Before discharging an anxious client, which information about anxiety would the nurse teach the family? o Anxiety is a totally unique feeling and experience. o Apprehension is generalized to the total environment. o Fears results from conscious actions, thoughts, and wishes. o Anxiety is a pattern of emotional and behavioral responses to stress.
o Anxiety is a pattern of emotional and behavioral responses to stress. · Anxiety is a human response consisting of both physical and emotional changes that everyone experiences when faced with stressful situations. Anxiety is experienced to a greater or lesser degree by every person. Apprehension is usually related to a specific aspect of the environment rather than the total environment. Fears are not intentionally or consciously generated.
Which approach would the nurse use when managing the care of a client diagnosed with generalized anxiety disorder (GAD)? o Creating an anxiety-free environment for the client o Assisting the client with the development of healthy, adaptive coping mechanisms o Avoiding triggers that produce anxiety in the client o Providing reinforcement that the client's anxiety issues can be eliminated
o Assisting the client with the development of healthy, adaptive coping mechanisms · The nurse would assist the client with the development of healthy, adaptive coping mechanisms. GAD is characterized by the maladaptive use of worrying as a coping mechanism. The ultimate goal is for the nurse to help the client replace the ineffective worrying with effective, healthy coping mechanisms. It is not possible or even desirable to create an anxiety-free environment; the goal is to help the client learn to deal with anxiety in a healthy manner. Although identifying triggers is an appropriate outcome, avoiding the triggers is usually not possible. It is not appropriate to falsely reassure the client that anxiety issues can be eliminated; all individuals experience anxiety and must appropriately learn to cope with those anxieties.
Which action would the nurse take for a client with alcohol withdrawal delirium? o Keep the client calm by applying wrist restraints. o Encourage the client to relate the content of hallucinations. o Assure the client that the symptoms are part of the withdrawal syndrome. o Dim the client's room lights to counter the visual distortions being experienced.
o Assure the client that the symptoms are part of the withdrawal syndrome. · Assuring the client that the symptoms are part of the withdrawal syndrome provides reality-based feedback for the client who is withdrawing from alcohol. Physical restraints will increase agitation and should be applied only as a last resort. Encouraging the client to relate the content of hallucinations focuses on the hallucinations rather than on reality. Shadows will increase the chance of visual distortions and illusions that occur during the withdrawal syndrome if the nurse dims the lights.
Which intervention would the nurse expect to implement to alleviate anxiety for a preoperative client? o Attempt to identify the client's concerns. o Reassure the client that the surgery is routine. o Report the client's anxiety to the health care provider. o Provide privacy by pulling the curtain around the client.
o Attempt to identify the client's concerns. · The nurse would assess the situation before planning an intervention. Reassuring the client that the surgery is routine minimizes concerns and cuts off communication. Reporting the client's anxiety to the health care provider is premature; more information is needed. The nurse needs more information; pulling the curtain may make the client feel isolated, which may increase anxiety.
According to Alcoholics Anonymous, which member of the health care team has the primary responsibility for the success of the therapy and rehabilitation? o Nurse o Client o Counselor o Psychiatrist
o Client · According to the philosophy of Alcoholics Anonymous, the client who has problems with alcohol must identify her or his own need to seek help and become the primary rehabilitator. The nurse gives support. The counselor gives direction. The psychiatrist prescribes treatments.
Which medication class is preferred for managing anxiety disorders? o Anticholinergics o Lithium carbonate o Antipsychotic medications o Selective serotonin reuptake inhibitors
o Selective serotonin reuptake inhibitors · Selective serotonin reuptake inhibitors have better safety profiles and do not carry the risk of substance abuse and tolerance. Anticholinergics are administered concurrently with antipsychotics to minimize extrapyramidal side effects. Lithium carbonate is a medication used to treat bipolar disorder. Antipsychotics are administered to clients with thought disorders.
Which mechanism of action explains why naloxone is administered for a heroin overdose? o Competition with opioids for occupancy of opioid receptors o Blunts severity of withdrawal symptoms as heroin wears off o Accelerated metabolism of heroin and stimulation of respiratory centers o Stimulation of cortical sites that control consciousness and cardiovascular function
o Competition with opioids for occupancy of opioid receptors · Naloxone is used to treat opioid-induced apnea. It competes with the opioid for central nervous system receptor sites and thus acts as an opioid antagonist. Preventing excessive withdrawal symptoms as heroin wears off is not the specific action of this medication. Naloxone does not accelerate the metabolism of heroin. Stimulating cortical sites that control consciousness and cardiovascular function also is not the action of naloxone. One adverse reaction of naloxone is cardiovascular irritability.
A primary health care provider prescribes 0.25 mg of alprazolam by mouth three times a day for a client with anxiety and physical symptoms related to work pressures. For which side effect of this medication will the nurse monitor the client? o Drowsiness o Bradycardia o Agranulocytosis o Tardive dyskinesia
o Drowsiness · Alprazolam, a benzodiazepine, potentiates the actions of gamma-aminobutyric acid, enhances presympathetic inhibition, and inhibits spinal polysynaptic afferent pathways. Drowsiness, dizziness, and blurred vision are common side effects. Alprazolam may cause tachycardia, not bradycardia. Agranulocytosis is usually a side effect of the antipsychotics in the phenothiazine group, not benzodiazepines. Tardive dyskinesia occurs after prolonged therapy with antipsychotic medications; alprazolam is an antianxiety medication, not an antipsychotic.
An individual is found unconscious and is admitted to the hospital with heroin overdose. Which nursing action is the priority? o Monitoring level of consciousness o Establishing a patent airway o Monitoring for heroin withdrawal o Establishing a therapeutic relationship
o Establishing a patent airway · The client is unconscious and unable to meet physical needs; a patent airway, breathing, and circulation are essential needs. Monitoring level of consciousness would be the next priority. Symptoms of heroin withdrawal will occur 6 to 8 hours after the last dose if the client has a physical addiction. Establishment of a therapeutic relationship will increase in importance once the client's physical condition has stabilized.
A 45-year-old client who recently completed alcohol detoxification reports plans to begin using disulfirams as part of the alcoholism treatment regimen. Which client teaching would the nurse share regarding this medication? o Voluntary compliance with the disulfiram regimen is very high. o A single dose of oral disulfiram will be effective for up to 72 hours. o Disulfiram may be taken intramuscularly and will be effective for as long as 7 days. o Foods, medications, and any topical preparation containing alcohol should be avoided.
o Foods, medications, and any topical preparation containing alcohol should be avoided. · Disulfiram causes unpleasant physical effects when mixed with alcohol. Any substance that contains alcohol may trigger an adverse reaction. Voluntary compliance with the use of disulfiram is often very low because of the negative physical effects experienced by the individual if alcohol is ingested. For disulfiram to be effective, it must be taken orally every day. Disulfiram is not administered intramuscularly.
Which emergency treatments are the priority for a client who intentionally took an overdose of a tricyclic antidepressant? Select all that apply. o Administration of physostigmine as soon as possible o Make a "no-suicide" contract with the client o Gastric lavage with activated charcoal o Intravenous anticholinergic to stabilize vital signs o Support of physiological function o Cardiac monitoring for arrhythmias or electrocardiogram (ECG) changes
o Gastric lavage with activated charcoal o Support of physiological function o Cardiac monitoring for arrhythmias or electrocardiogram (ECG) changes · Gastric lavage with charcoal may help decrease the level of tricyclic antidepressant overdose. Supportive measures such as mechanical ventilation may be needed until the medical crisis passes. Tricyclic antidepressants can cause arrhythmias and ECG changes. Physostigmine salicylate was used in the past to promote improvement in consciousness. Now its use is contraindicated because it can cause bradycardia, asystole, and seizures in clients with tricyclic antidepressant toxicity. A no-suicide contract is eventually discussed with the client; however, emergency interventions are priority. The acetylcholine level is depressed as a result of the tricyclic antidepressant; anticholinergics are most effective in managing the side effects of antipsychotic and neuroleptic medications, not tricyclic antidepressant medications.
A client with a history of alcoholism develops Wernicke encephalopathy associated with Korsakoff syndrome. Which medication therapy is indicated for management of this condition? o Traditional phenothiazines o Judicious use of antipsychotics o Intramuscular injections of thiamine o Oral administration of chlorpromazine
o Intramuscular injections of thiamine · Thiamine is a coenzyme necessary for the production of energy from glucose. If thiamine is not present in adequate amounts, nerve activity is diminished and damage or degeneration of myelin sheaths occurs. A traditional phenothiazine is a neuroleptic antipsychotic that should not be prescribed because it is hepatotoxic. Antipsychotics must be avoided; their use has a higher risk of toxic side effects in older or debilitated persons. Chlorpromazine, a neuroleptic, cannot be used because it is severely toxic to the liver.
A health care provider prescribes disulfiram for a client who abuses alcohol. The nurse teaches the client that disulfiram will have which action? o It decreases alcohol cravings. o It decreases the effect of alcohol inebriation. o It allows the client to tolerate only small amounts of alcohol. o It causes a severe adverse reaction if alcohol is consumed.
o It causes a severe adverse reaction if alcohol is consumed. · Disulfiram is used for aversion therapy; a person who consumes alcohol while taking disulfiram will experience a severe reaction consisting of nausea, vomiting, hypotension, headache, tachycardia, tachypnea, and flushing. The medication does not decrease alcohol cravings, and it does not decrease inebriant effects. When taking disulfiram, the client cannot tolerate any alcohol.
For a client with obsessive-compulsive disorder, which event will increase the client's anxiety level? o The day progresses and the sun is close to setting. o Family members come to the unit to visit. o The nurse performs the morning physical assessment. o Limits are set on the performance of a ritual.
o Limits are set on the performance of a ritual. · Setting limits on the performance of a ritual will increase the client's anxiety. The ritual is a defense that controls anxiety. The client needs time to develop other defenses before the ritual can be limited. The precipitation of anxiety in a client with obsessive-compulsive disorder is usually unrelated to the time of day. Sundowning is an increase in confusion (in the early evening) seen in clients with dementia. Visits from the family or physical assessment by the nurse could precipitate anxiety for any client, but nonjudgmental and supportive attitudes should decrease anxiety.
Which outcome would indicate a client who was hospitalized with severe anxiety is ready to be discharged? o Follows rules of the milieu o Maintains anxiety at a manageable level o Verbalizes positive aspects about the self o Recognizes that hallucinations can be controlled
o Maintains anxiety at a manageable level · Maintaining anxiety at a manageable level would indicate the client is ready to be discharged. Maintenance of anxiety at a manageable level results from teaching the client to recognize situations that provoke anxiety and how to institute measures to control its development. Following the rules of the milieu and verbalizing positive aspects about the self are not priority outcomes for discharge; the client has probably had little difficulty in these areas. No evidence was presented in the scenario to indicate that the client is hallucinating.
A client with a 20-year history of excessive alcohol use has developed jaundice and ascites and is admitted to the hospital. Which is the priority nursing action during the first 48 hours after the client's admission? o Monitor vital signs. o Identify a plan to reduce alcohol intake. o Obtain a foam mattress. o Improve nutritional status.
o Monitor vital signs. · The vital signs, especially pulse and temperature, will increase before the client demonstrates any of the more severe signs and symptoms of withdrawal from alcohol. Identifying a plan to reduce alcohol intake upon discharge is important, but it is not the priority. Although the client will be more comfortable on a foam mattress, it is not the priority. Improving nutritional status becomes a priority after problems of the withdrawal period have subsided.
In the rehabilitation of a client addicted to alcohol, which factor is most important? o Motivational readiness o Availability of community resources o Accepting attitude of the family o Level of the client's physical state
o Motivational readiness · Intrinsic motivation (stimulated from within) is essential if rehabilitation is to be successful. Often clients are most emotionally ready for help when they have "hit bottom." Only then are they ready to face reality and put forth the necessary energy and effort to change behavior. Community resources, physical state, and family have less effect on the success of rehabilitation.
Thiamine (vitamin B1) and niacin (vitamin B3) are prescribed for a client with alcoholism. Which body function maintained by these vitamins will the nurse monitor? o Neuronal activity o Bowel elimination o Efficient circulation o Prothrombin development
o Neuronal activity · Thiamine and niacin help convert glucose for energy and influence nerve activity. These vitamins do not affect elimination. These vitamins are not related to circulatory activity. Vitamin K, not thiamine and niacin, is essential for the manufacture of prothrombin.
When naloxone has been administered to a client with an opiate overdose, which action is most important for the nurse to take? o Question client about pain level. o Monitor for increased heart rate. o Observe respiratory rate and depth. o Check for alertness and orientation.
o Observe respiratory rate and depth. · Naloxone is given for decreased respirations or respiratory arrest caused by opioid overdose. Although the client may express increased pain after use of naloxone, asking about pain is not a priority action. Heart rate may change when the client respiratory effort and oxygenation improve, but this is not the most important parameter to assess. Alertness and orientation are likely to improve with naloxone administration, but the priority assessment is respiratory effort and rate.
Which behavior by the client would indicate to the nurse that a client has successfully achieved the long-term outcome of using effective coping responses when feelings of anxiety begin? o Performs a relaxation exercise o Gets involved in some type of quiet activity o Avoids the situation that precipitated the anxiety o Examines carefully what precipitated the anxiety
o Performs a relaxation exercise · The nurse would realize that effective coping has taken place when the client performs a relaxation exercise. Relaxation techniques refocus energy and eventually ease physical and emotional stress. Getting involved in some type of quiet activity is not always possible; forced quiet activity may increase stress and anxiety rather than reduce it. Avoiding the situation that precipitated the anxiety would not indicate effective coping; stress can develop from a variety of feelings stimulated by many situations. Although examining what precipitated the anxiety is appropriate after the incident, it is not an effective coping response for when feelings of anxiety begin.
To determine the effectiveness of therapy, which behavior would the nurse assess for in a client with generalized anxiety disorder? o Participating in activities o Learning how to avoid anxiety o Taking medications as prescribed o Recognizing when anxiety is developing
o Recognizing when anxiety is developing · Recognition of anxiety or symptoms of increasing anxiety is an indication that the client is improving. Participating in activities does not indicate improvement or recognition of feelings; the client may be doing what others expect. Avoidance of anxiety is not a good indication of improvement; there is no guarantee that anxiety can always be avoided. Taking medications as prescribed does not indicate improvement or recognition of feelings; the client may be doing what others expect.
Which characteristic distinguishes post-traumatic stress disorders from other anxiety disorders? o Lack of interest in family and others o Reliving the trauma in dreams and flashbacks o Avoidance of situations that resemble the stress o Blunted affect when discussing the traumatic situation
o Reliving the trauma in dreams and flashbacks · Experiencing the actual trauma in dreams or flashbacks is the major symptom that distinguishes post-traumatic stress disorders from other anxiety disorders. Lack of interest in family and others is usually not associated with anxiety disorders. Avoidance of situations that resemble the stress is more common with phobic disorders. Blunted affect that occurs during discussion of a traumatic situation is more characteristic of acute stress disorder.
Which action would the nurse take first for a client who comes to a mental health center with severe anxiety, evidenced by crying, hand-wringing, and pacing? o Stay physically close to the client. o Gently ask what is bothering the client. o Tell the client to try to relax by sitting quietly. o Get the client involved in a nonthreatening activity.
o Stay physically close to the client. · The nurse would first stay physically close to the client. By staying physically close to the client during the time of severe anxiety, the nurse conveys the message that someone cares enough to be there during this frightening incident and that the client is a person worthy of care. Gently asking what is bothering the client will occur later after the client's anxiety has decreased. Sitting still will increase the tension the client is experiencing. Involving the client in a nonthreatening activity is not an initial nursing intervention; this will come later after the anxiety has abated.
Which intervention would provide comfort to the client experiencing alcohol toxicity? o Dim the lights. o Use distraction. o Offer activities. o Stay with the client.
o Stay with the client. · Agitation and anxiety are common in clients experiencing alcohol toxicity. Staying with the client as much as possible will help decrease their anxiety and provide the opportunity to reorient them as needed. Dimming the lights may place the client at risk for injury due to their impaired judgment and lack of coordination. Distraction and activities are not appropriate nursing interventions at this time.
